APPLICATION FOR OCCASIONAL STUDY
OCCASIONAL STUDY UNITS MUST BE PAID IN FULL PRIOR TO COMMENCEMENT OF STUDY
Please return this application form with the appropriate documentation personally to the Faculty.
A non-refundable application fee of R100 is payable by SA citizens, R700 by international applicants.
PLEASE COMPLETE FORM IN BLOCK LETTERS
GENERAL INFORMATION
When do you wish to commence study?
Year
Month (e.g.Dec)
Have you ever applied to and/or been registered at Wits before?
Yes
No
If yes, please quote student/person number
PERSONAL DETAILS
Please use capital letters
Title
Ms
Mr
Miss
Other
Last name/Surname
First name
Middle name/s
Gender (please tick )
Female
Date of birth
Male
Day
Month (e.g.Dec) Year
CITIZENSHIP
Are you a South African citizen?/ a permanent resident? Yes
No
If yes, attach certified proof of SA ID or PR document
South African Identity no.
If not South African permanent resident, state nationality
Passport number
If not South African permanent resident, state the country you have permanent residence in
Indicate your Immigration status (where applicable) Asylum Seeker
Refugee
DETAILS OF CHANGE OF NAMES IF ANY
Name change (if applicable)
Previous first name (if applicable)
Date of name change
Day
Month (e.g.Dec)
Previous surname (if applicable)
Year
Reason for name change
GENERAL BACKGROUND
Marital status (Please tick √)
Population Group (Please tick √) (Required for statistical purposes)
Black
Coloured
Indian
White
Chinese
Single
Divorced
Married
Separated
Widow/er
Religious affiliation (Required for accommodation and bursary purposes) (Please tick √)
Christian
Hindu
Muslim
Jehovah’s
Witness
Jewish
None
Other (Please specify)
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Home Language (Please tick √)
Afrikaans
German
Portuguese
Setswana
Isizulu
English
Greek
Sepedi
Siswati
Tshivenda
Chinese
Ndebele
SeSotho
Sixhosa
Xitsonga
French
Italian
Other (Please specify)
In order for the University to provide necessary services, we need you to indicate your disability status at the time of your application. If you do
not, the University cannot undertake to provide such assistance. Every reasonable attempt will be made to provide you with the assistance you
may need as a result of your disability.
Disability/
Special needs
(Please tick √)
Other (Please specify)
Blindness
ADD/ADHD (chronic)
Cerebral palsy
Deafness
Learning disability e.g. Dyslexia
Impaired mobility
Partial hearing
Speech
Paraplegic
Partially sighted
PREVIOUS ACTIVITIES
University
Quadriplegic
What has been your MAIN ACTIVITY in the previous year? (e.g. working/student/school). (Please tick √)
College
School
Employment
Gap Year (maximum one year after matric)
Sports Involvement: (please state in which sports you have participated if any and at what level)
Sport
Level (School, Club, Junior / Senior Provincial; Junior / Senior National)
1.
2.
CONTACT DETAILS (ALL DETAILS MUST BE COMPLETED)
APPLICANT’S PERSONAL DETAILS
Physical Address
City:
Province
Country
Postal code
Postal Address
City
Province
Country
Postal code
Contact Numbers
Home number
Cell number
Business number
Fax
Email
NEXT-OF-KIN DETAILS
Relationship
Mother
Father
Other
Next-of-kin Surname
Next-of- kin First name
Next-of-kin Initials
Next-of-kin Title
Next-of-kin ID no.
Next-of-kin Postal Address
City
Province
Country
Next-of-kin
Contact numbers
Postal code
Home number
Cell number
Business number
Fax
Email
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CONTACT DETAILS (ALL DETAILS MUST BE COMPLETED)
DETAILS OF PERSON LIABLE FOR SETTLEMENT OF FEES
Surname
First name
Initials
Title
ID no.
Postal Address
City
Province
Country
Postal code
Contact numbers
Home number
Cell number
Business number
Fax
Email
ACADEMIC QUALIFICATIONS
Degree / Diploma
Fulltime
Parttime
Academic history (begin with most recent qualification)
Dates of Registration
From
To
Dates of
Graduation
Student
Number
Institution
If foreign institution provide address
and country
Membership of professional bodies (attach separate sheet if necessary)
Name of professional body
Name of qualification / title
Date awarded (YY/MM/DD)
EMPLOYMENT DETAILS
Please provide details: (attach separate sheet if necessary)
Are you currently employed?
Yes
No
How many years of full-time employment will you have completed by the end of this year?
JOB TITLE
NAME OF COMPANY / EMPLOYER
(please provide details of different positions with the
same employer)
CHOICE OF UNIT(S)
UNIT (SUBJECT / COURSE NAME)
PERIOD EMPLOYED (YY/MM/DD)
From
To
NB: Department must approve before submitting the application form
COURSE CODE
1.
2.
3.
4.
PURPOSE OF STUDY: ____________________________________________________________________________________________
________________________________________________________________________________________________________________
Departmental approval for unit choice: (Signature)_________________________________________________________________
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INDEMNITY AND UNDERTAKING
Applicants under the age of 18 years old must be assisted by their parent or guardian (must be the same person listed under next-of-kin on page 2).
LEGAL DECLARATION OF INDEMNITY AND UNDERTAKING
I, THE APPLICANT, AND I, THE PARENT/GUARDIAN/NEXT-OF-KIN OF THE APPLICANT –
(1) Acknowledge that the University does not accept responsibility for damage or loss in respect of property of the applicant or in respect of property brought onto
University premises by the applicant.
(2) Do hereby indemnify the University in respect of any damage caused by the applicant to University property or to the property of third parties, whether on or off
the University premises, as a result of the applicant’s actions either whilst on the University premises or whilst engaged in any activity related to the University.
(3) Undertake, during the orientation period and for any period during which I am a registered student, to be bound by the rules and regulations of the University
for the time being in force, including the rules and regulations of any University residence, club or society to which I may be admitted or become a member and
by any requirements or conditions imposed by the University on me as a prerequisite to my registration as a student of the University in any faculty.
(4) Certify that the information provided in this form and all supporting documentation is accurate and acknowledge that furnishing any false information may
result in disciplinary proceedings being taken against the applicant.
(5) Declare that I have furnished the University with all the information necessary to make an informed decision about my admission.
(6) Undertake to pay unconditionally all fees, charges and equipment surcharges payable to the University as they fall due for payment, for any period for which I
am or may become a registered student or the applicant is or may become a registered student of the University.
(7) Consent to my examination results being made available to the relevant bursary donor(s) and /or lenders.
ALL APPLICANTS MUST SIGN BELOW – Thank you
Signature of applicant:..............................................................................Date:..............................................................
AND, if the applicant is under the age of 18 years, assisted by (full name of parent or legal guardian or next-of-kin) :
.......................................................................................................................................................................................
First name
Last name / surname
Signature:..................................................................................................Date: ............................................................
PERSON LIABLE FOR SETTLEMENT OF FEES
I undertake to settle all tuition and miscellaneous fees due to the University by due date. I may make suitable arrangements to settle the outstanding charges as
per the University’s Credit Policy as stipulated by the National Credit Regulator. If I do not settle by due date, I will pay the interest at the rates as prescribed by the
University. I also consent to the University imposing credit control restrictions if the debt is not settled.
Full name........................................................................................................................................................................
Signature:..................................................................................................Date: ............................................................
NB: INTERNATIONAL STUDENTS: ALL FEES ARE DUE AND MUST BE PAID IN FULL ON OR BEFORE REGISTRATION
BEFORE YOU SUBMIT YOUR APPLICATION PLEASE NOTE:
Please ensure you have signed the indemnity above
This form must be accompanied by:
• Proof of payment
• Original matric certificate
• Original ID documents
• Original foreign school certificate if applicable
• Original full academic transcript and code of conduct
• Original marriage certificate if name has changed
Methods of payment
1. Via Internet transfer, or
2. Direct payment into: Standard Bank, Branch: Braamfontein (code: 004 805), Account Name: Wits University Application Fees, CI Number: 074A, Account Number: 200 346 385.
PLEASE ATTACH A COPY OF THE DEPOSIT SLIP OR PROOF OF INTERNET TRANSFER.
We do not accept cheque or cash payments.
PAYMENT INFORMATION (FOR OFFICE USE ONLY)
CASH
CHEQUE/ BANK DRAFT
ME
OTHER
BQ
CREDIT CARD
FA
AT
RES
BANKSLIP
Received by:
_______________________________________________
Date:
_____________________________________________________
Processed by:
______________________________________
Date:
__________________________________________
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